Tuesday, April 11, 2006

As the Iraq war has moved away from traditional combat into guerilla or insurgent warfare, an increasing amount of non-combat personnel are placed at greater risk. No longer are soldiers and Marines the only ones at risk for posttraumatic stress disorder. Female troops (who are supposedly kept from taking on combat roles), medics, administrators, and a variety of others in a supporting or staff role all are now exposed to traumatic conditions that often trigger PTSD: unexpected attacks, violence, and the feeling that one is never safe. Tacoma's News Tribune introduces us to one nurse's story.

The hug seemed to go on forever. Neither wanted to let go. Rory Dunn and Tina Sundem hadn’t seen each other since their lives briefly crossed in an Army hospital’s intensive-care unit in the middle of Baghdad’s Green Zone nearly two years ago.

Dunn is a former soldier from Renton who suffered a traumatic brain injury and other wounds near Fallujah, Iraq, in May 2004 when a roadside bomb exploded next to his Humvee. He has no memory of the earlier encounter. He was in a coma and given little chance of survival.

Capt. Sundem, an Army nurse who treated him and now lives in Pierce County, vividly remembers former Spc. Dunn. “He was so severely wounded I never imagined he would live,” she said.

The piece describes their recent meeting in a Tacoma, WA restaurant.

For Dunn, 23, the reunion was a chance to say thank you. But for Sundem, 34, it was another step in her own recovery. Sundem’s experience in Iraq left her so traumatized that she attempted suicide 10 days before her tour was to end. She was diagnosed with post-traumatic stress disorder. She spent time in a psychiatric ward at Walter Reed Army Medical Center in Washington, D.C. She’s found it therapeutic to write about her flashbacks from her home in Roy.

Sundem read about Dunn in The News Tribune last summer. She knew that seeing him would help her confront the darkest memories of her days in Iraq and take some comfort that her nursing skills, at least in Dunn’s case, paid off. “Since I came back from Iraq, I haven’t been able to touch a patient,” she said. “It’s so sad. That’s who I was. I was good at it. Others with PTSD can go on to become bankers or lawyers. But the thing I am, I can’t be anymore.”

Stats on PTSD are given. Then, a closer look at the unique experience of combat-zone medical personnel:

Maj. Gen. George Weightman, who oversees Army medical training, said the Army tries to prepare its medical personnel for what they will face at military hospitals in Iraq. “We call them trauma factories,” Weight­man said. “It can be a shock when 12 or 15 wounded arrive all at once. In the states, you see people injured in car accidents or wounded by guns or knives. You don’t see high-velocity or explosion wounds. It can get pretty intense.”

Health care professionals in any setting can suffer from “compassion fatigue,” a form of burnout. PTSD, however, can be far more serious. “We are trained to be objective and not grossed out by the blood and gore,” Weightman said. “But at some point – who knows what will trigger it – the emotional floodgates open. As a civilian you can get away from it. In a combat zone you can’t.”

Dr. Jeffrey Poffenbarger served in Iraq with the 31st Combat Support Hospital along with Tina Sundem.

Though the months he spent in the Baghdad are a blur, Poffenbarger said he remembers Dunn. Medical teams thought they had lost him a couple of times. He’s pleased that Dunn survived and would like to go hunting and fishing with him.

Poffenbarger seemed uncomfortable when asked about Sundem, though he did say he understood the stress she and other nurses were under. In many ways, Poffenbarger said the nurses in the Baghdad ICU had it tougher than the doctors, because they provided care 12 or 16 hours a day for six or seven days at a stretch. “It was very hard on some,” he said.

Others who served with the 31st Combat Support Hospital in Baghdad say that since returning they are a little edgier, a little angrier and a little less tolerant. “Everyone who goes there comes backed changed,” said Maj. Nancy Parson, an ICU nurse who was in Baghdad for a year. “You would do everything you could, and they would still die. Sometimes it felt like no matter what you did it wasn’t enough.”

Maj. Mark Brown, a psychiatrist who served in Baghdad and now works with Parson at Fort Bliss in Texas, said the stress came from more than just treating the wounded. Gunfire and mortar attacks caused him to worry about the mental health of those he worked with. “As a psychiatrist, I spent a little part of every day trying to think about what could help them,” he said.

Sundem came out of a military family, so it wasn't a surprise that she enlisted with the Army. Three days after receiving her orders, she was off to Iraq.

Sundem chooses words carefully as she talks about her time in Iraq. Her kids, Hannah, 4, and Bridger, 3, keep popping out of the family room, where they were supposed to be watching a video. She shoos them away as she talks about the carnage she dealt with in Baghdad. “I can’t describe the horror,” she said. “I swiped a wounded soldier’s eyeball into a trash can. At times I would think, ‘This kid isn’t going to make it, this kid will be a vegetable.’ It was never ending. There was no escape.”

Sundem said she worked 14- or 16-hour days, six days a week, and the ICU was always filled to capacity. If it wasn’t U.S. soldiers, it was coalition soldiers, wounded civilians, including children, or enemy combatants. Trash cans overflowed with empty transfusion bags and the wrappers from burn pads. Intercranial pressure monitors and intravenous pumps continually beeped. She recalls soldiers without legs or arms or faces.

One night as she tried to sleep, the blast from a mortar shell shattered the window, spraying her bed with glass shards. But Sundem said it was not the danger of living and working in a war zone that got to her. More than anything, it was the wounded. “I would lean over and whisper in their ears, ‘You aren’t going to die on my watch,’” she said.

With the pressure she placed on herself, and the horrific conditions swirling around her, she began her descent:

She said she began feeling hostile toward her co-workers and, especially, the enemy combatants she treated. At one point, she didn’t sleep for four days. “I called [my husband] Chad, wishing someone could make this stop,” she said.

Sundem did seek help. She was on medication and had been in contact with a psychiatrist. But near the end of her year in Baghdad, she snapped when she heard a doctor had bad-mouthed her care. She tried to commit suicide but survived, and the Army sent her to a hospital in Landstuhl, Germany. “I was a zombie when I got to Germany,” she said. “One doctor said I was the worst case of PTSD he had ever seen.”

While in Germany, Sundem said she couldn’t call home, at first. “I was afraid to come home,” she said. “I had changed. When I went over there I was a successful, happy person. Every premise of my value system was challenged and destroyed. I had lost my faith in God. I had lost my faith in humanity. I felt soiled and impure. I felt like a monster. I didn’t want to poison my children, and I was ashamed of what my family would see in me.”

She's received treatment at Walter Reed. And while she's on the Army’s temporary disability retirement list, she could be redeployed within the next five years. Her husband has already served two tours in Iraq, and one in Afghanistan. She takes each day as it comes, slowly getting her life back in order.

The flashbacks come mostly when her mind is idle. “I can feel them coming,” she said. “It’s like I am there, the smells, the sounds.”

As the flashbacks sweep over her, she retreats to her favorite living room easy chair, pulls out her laptop and writes. She has written a book she titled “Lest They Be Forgotten: An Army Nurse’s Memoirs.” No publisher has shown interest yet. But Sundem said it has been therapeutic and is a story that needs to be told. She will continue seeking a publisher.

Senior Army officials say PTSD and other mental health issues are major concerns with troops returning from Iraq, including medical staff. They have made counseling and treatment a priority. Col. Gregory Gahm, the chief of psychology at Madigan Army Medical Center at Fort Lewis, said his staff works hard to treat Iraq veterans who are facing mental problems. “We are able to help most of them,” he said.

The piece closes back in the restaurant, as she and a soldier she'd treated reunite to help them heal the wounds of their Iraq experience.

Dunn’s mother, Cynthia Lefever, said her son hoped the reunion would help Sundem get on with her life. Lefever hopes the story about her son’s survival would reassure others like Sundem that their efforts were appreciated. “She saw this tall, dark, handsome young man with half his face blown away, and he lived,” she said. “I’m hoping Rory’s story will sent a message for the caregivers to never, ever give up hope and to continue to give the best care possible.”

No one seemed to want the evening to end, but it was time for goodbyes and a final hug. “Rory, you are a miracle,” Sundem said.

“You were a good nurse. You did a good job,” he replied.

Please thank the Tacoma News Tribune for giving coverage to this important issue by publishing such a thoughtful and educational piece. And I'd like to thank the troops and their caregivers for all they do as they wear our nation's uniform.

While a wide variety of events can trigger what's called post-traumatic stress disorder, this PTSD blog focuses solely on the combat-related variety.
As a new generation of warriors returns to civilian life and seeks out resources, PTSD Combat is here to help.

Considerable Quotes

"The first shamans earned their keep in primitave societies by providing explanations and rituals that enabled man to deal with his environment and his personal anguish. Early man, no less than we, dealt with forces that he could not understand or control, and he attempted to come to grips with his vulnerablity by trying to bring order to his universe." -- Richard Gabriel in No More Heroes

"War stories end when the battle is over or when the soldier comes home. In real life, there are no moments amid smoldering hilltops for tranquil introspection. When the war is over, you pick up your gear, walk down the hill and back into the world." -- OIF vet John Crawford in The Last True Story I'll Ever Tell

"After wars' end, soldiers once again become civilians and return to their families to try to pick up where they left off. It is this process of readjustment that has more often than not been ignored by society. -- Major Robert H. Stretch, Ph.D in Textbook of Military Medicine: Vol. 6 Combat Stress

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